Freud - Complete Works (78 page)

   Where there is a case in which
symptoms of neurasthenia and of anxiety neurosis are combined -
where, that is, we have a mixed case - we have only to keep to our
proposition, empirically arrived at, that a mingling of neuroses
implies the collaboration of several aetiological factors, and we
shall find our expectation confirmed in every instance. How often
these aetiological factors are linked with one another organically,
through the interplay of sexual processes - for instance, coitus
interruptus or insufficient potency in the man, going along with
masturbation - would well deserve separate discussion.

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   Having diagnosed a case of
neurasthenic neurosis with certainty and having classified its
symptoms correctly, we are in a position to translate the
symptomatology into aetiology; and we may then boldly demand
confirmation of our suspicions from the patient. We must not be led
astray by initial denials. If we keep firmly to what we have
inferred, we shall in the end conquer every resistance by
emphasizing the unshakeable nature of our convictions. In this way
we learn all sorts of things about the sexual life of men and
women, which might well fill a useful and instructive volume; and
we learn, too, to regret from every point of view that sexual
science is even to-day still regarded as disreputable. Since minor
deviations from a normal
vita sexualis
are much too common
for us to attach any value to their discovery, we shall only allow
a serious and long continued abnormality in the sexual life of a
neurotic patient to carry weight as an explanation. Moreover, the
idea that one might, by one’s insistence, cause a patient who
is psychically normal to accuse himself falsely of sexual
misdemeanours - such an idea may safely be disregarded as an
imaginary danger.

   If one proceeds in this manner
with one’s patients, one also gains the conviction that, so
far as the theory of the sexual aetiology of neurasthenia is
concerned, there are no negative cases. In my mind, at least, the
conviction has become so certain that where an interrogation has
shown a negative result, I have turned this to account too for
diagnostic purposes. I have told myself, that is, that such a case
cannot be one of neurasthenia. In this way I have been led in
several instances to assume the presence of progressive paralysis
instead of neurasthenia, because I had not succeeded in
establishing the fact - a fact that was necessary for my theory -
that the patient indulged very freely in masturbation; and the
further course of those cases later confirmed my view. In another
instance the patient, who exhibited no clear organic changes,
complained of intracranial pressure, headaches and dyspepsia, but
countered my suspicions about his sexual life straightforwardly and
with unshaken certainty; and the possibility occurred to me that he
might have a latent suppuration in one of his nasal sinuses. A
specialist colleague of mine confirmed this inference I had made
from the negative sexual results of my interrogation, by removing
the pus from the patient’s antrum and relieving him of his
ailments.

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   The appearance of there
nevertheless being ‘negative cases’ can arise in
another way as well. Sometimes an interrogation discloses the
presence of a normal sexual life in a patient whose neurosis, on a
superficial view, does in fact closely resemble neurasthenia or
anxiety neurosis. But a more deep -going investigation regularly
reveals the true state of affairs. Behind such cases, which have
been taken for neurasthenia, there lies a psychoneurosis - hysteria
or obsessional neurosis. Hysteria in especial, which imitates so
many organic affections, can easily assume the appearance of one of
the ‘actual neuroses’ by elevating the latter’s
symptoms into hysterical ones. Such hysterias in the form of
neurasthenia are not even very rare. Falling back on psychoneurosis
when a case of neurasthenia shows a negative sexual result, is,
however, no cheap way out of the difficulty; the proof that we are
right is to be obtained by the method which alone unmasks hysteria
with certainty - the method of psycho-analysis, to which we shall
refer presently.

   There may perhaps be some,
however, who are quite willing to recognize the sexual aetiology in
their neurasthenic patients, but who nevertheless blame it as
one-sidedness if they are not asked to pay attention as well to the
other factors which are always mentioned by the authorities as
causes of neurasthenia. Now it would never occur to me to
substitute a sexual aetiology in neuroses for every other
aetiology, and so to assert that the latter have no operative
force. This would be a misunderstanding. What I think is rather
that in addition to all the familiar aetiological factors which
have been recognized - and probably correctly so - by the
authorities as leading to neurasthenia, the sexual factors, which
have not hitherto been sufficiently appreciated, should also be
taken into account. In my opinion, however, these sexual factors
deserve to be given a special place in the aetiological series. For
they alone are never absent in any case of neurasthenia, they alone
are capable of producing the neurosis without any further
assistance, so that those other factors seem to be reduced to the
role of an auxiliary and supplementary aetiology, and they alone
allow the physician to recognize firm relations between their
manifold nature and the multiplicity of the clinical pictures. If,
on the other hand, I group together all the patients who have
ostensibly become neurasthenic from overwork, emotional agitation,
as an after-effect of typhoid fever, and so on, they show me
nothing in common in their symptoms. The nature of their aetiology
gives me no idea of what kind of symptoms to expect, any more than,
conversely, does the clinical picture they present enable me to
infer what aetiology is at work in them.

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   The sexual causes, too, are the
ones which most readily offer the physician a foothold for his
therapeutic influence. Heredity is no doubt an important factor,
when it is present; it enables a strong pathological effect to come
about where otherwise only a very slight one would have resulted.
But heredity is inaccessible to the physician’s influence;
everyone is born with his own hereditary tendencies to illness, and
we can do nothing to change them. Nor should we forget that it is
precisely in regard to the aetiology of the neurasthenias that we
must necessarily deny the first place to heredity. Neurasthenia (in
both its forms) is one of those affections which anyone may easily
acquire without having any hereditary taint. If it were otherwise,
the enormous increase in neurasthenia, of which all the authorities
complain, would be unthinkable. In what concerns civilization,
among whose sins people so often include responsibility for
neurasthenia, these authorities may indeed be right (although the
way in which this comes about is probably quite different from what
they imagine). Yet the state of our civilization is, once again,
something that is unalterable for the individual. Moreover this
factor, being common to all the members of the same society, can
never explain the fact of selectivity in the incidence of the
illness. The physician who is not neurasthenic is exposed to the
same influence of an allegedly detrimental civilization as the
neurasthenic patient whom he has to treat. Subject to these
limitations, the factors of exhaustion retain their significance.
But the element of ‘overwork’, which physicians are so
fond of producing to their patients as the cause of their neurosis,
is too often unduly misused. It is quite true that anyone who,
owing to sexual noxae, has made himself disposed to neurasthenia,
tolerates intellectual work and the psychical exigencies of life
badly; but no one ever becomes neurotic through work or excitement
alone. Intellectual work is rather a protection against falling ill
of neurasthenia; it is precisely the most unremitting intellectual
workers who remain exempt from neurasthenia, and what neurasthenics
complain of as ‘overwork that is making them ill’ 
does not as a rule deserve to be called ‘intellectual
work’ at all, either in its quality or quantity. Physicians
will have to become accustomed to explaining to an office-worker
who has been ‘overworked’ at his desk or to a housewife
for whom her domestic activities have become too heavy, that they
have fallen ill, not because they have tried to carry out duties
which are in fact easily performed by a civilized brain, but
because all the while they have been grossly neglecting and
damaging their sexual life.

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   Furthermore, it is only the
sexual aetiology which makes it possible for us to understand all
the details of the clinical history of neurasthenics, the
mysterious improvements in the middle of the course of the illness
and the equally incomprehensible deteriorations, both of which are
usually related by doctors and patients to whatever treatment has
been adopted. In my records, which include more than two hundred
cases, there is, for instance, the story of a man who, when the
treatment prescribed by his family physician had done him no good,
went to Pastor Kneipp and for a year after being treated by him
showed an extraordinary improvement in the middle of his illness.
But when, a year later, his symptoms grew worse once more and he
again went to Wörishofen for help, the second treatment was
unsuccessful. A glance into the patient’s family record
solved the double riddle. Six and a half months after his first
return from Wörishofen his wife bore him a child. This meant
that he had left her at the beginning of a pregnancy of which he
was not yet aware; after his return he was able to practise
natural
intercourse with her. At the close of this period,
which had a curative effect on him, his neurosis was started up
afresh by his once more resorting to coitus interruptus; the second
treatment was bound to prove a failure, since this pregnancy of his
wife’s remained her last.

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   There was a similar case, in
which, once again, the treatment had an unexpected effect which
called for an explanation. This case turned out to be still more
instructive, for it exhibited a puzzling alternation in the
symptoms of the neurosis. A young neurotic patient had been sent by
his physician to a reputable hydropathic establishment on account
of a typical neurasthenia. There his condition steadily improved at
first, so that there was every prospect that he would be discharged
as a grateful disciple of hydrotherapy. But in the sixth week a
complete change occurred; the patient ‘could no longer
tolerate the water’, became more and more nervous, and
finally left the establishment after two more weeks, uncured and
dissatisfied. When he complained to me about this therapeutic fraud
I asked him a few questions about the symptoms which had overtaken
him in the middle of the treatment. Curiously enough, a complete
change had come over them. He had
entered
the sanatorium
with intracranial pressure, fatigue and dyspepsia; what had
troubled him
during
the treatment were excitement, attacks
of dyspnoea, vertigo in walking, and disturbances of sleep. I was
now able to say to him: ‘You are doing hydrotherapy an
injustice. As you yourself very well knew, you fell ill as a result
of long-continued masturbation. In the sanatorium you gave up this
form of satisfaction, and therefore you quickly recovered. When you
felt well, however, you unwisely sought to have relations with a
lady - a fellow-patient, let us suppose - which could only lead to
excitement without normal satisfaction. The beautiful walks in the
neighbourhood of the establishment gave you ample opportunity for
this. It was this relationship, not a sudden inability to tolerate
hydrotherapy, which caused you to fall ill once more. Moreover,
your present state of health leads me to conclude that you are
continuing this relationship here in town as well.’ I can
assure my readers that the patient confirmed what I said, point by
point.

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466

   The present treatment of
neurasthenia - which is, perhaps, carried out most successfully in
hydropathic establishments - has as its aim the amelioration of the
nervous condition by means of two factors: shielding the patient
and strengthening him. I have nothing to say against such a method
of treatment, except that it takes no account of the circumstances
of the patient’s sexual life. According to my experience, it
is highly desirable that the medical directors of such
establishments should become properly aware that they are dealing,
not with victims of civilization or heredity, but -
sit venia
verbo
- with people who are crippled in sexuality. They would
then, on the one hand, be more easily able to account for their
successes as well as their failures; and, on the other, they would
achieve new successes which, till now, have been at the mercy of
chance or of the patient’s unguided behaviour. If we take a
neurasthenic woman, suffering from anxiety, away from her home and
send her to a hydropathic establishment, and if there, freed from
all duties, she is made to bathe and take exercise and eat plenty
of food, we shall certainly be inclined to think that the
improvement - often a brilliant one - which is achieved in a few
weeks or months is due to the rest which she has enjoyed and to the
invigorating effects of hydrotherapy. That may be so: but we are
overlooking the fact that her removal from home also entails an
interruption of marital intercourse, and that it is only the
temporary elimination of this pathogenic cause which makes it
possible for her to recover under favourable treatment. Neglect of
this aetiological point of view brings its subsequent revenge, when
what seemed such a gratifying cure turns out to be a very
transitory one. Soon after the patient has returned to ordinary
life the symptoms of the complaint appear once more and oblige him
either to spend a part of his existence unproductively from time to
time in establishments of this kind or to direct his hopes of
recovery elsewhere. It is therefore clear that with neurasthenia
the therapeutic problems must be attacked, not in hydropathic
institutions but within the framework of the patient’s
life.